NCCAOM/Dry Needling/A Young Profession

A survey about the possibility of a new NCCAOM certificate in Facial Rejuvenation showed up a few days ago. The online conversations were a reminder that many of us are confused about the NCCAOM — what their role is, what we want their role to be , what their role “should” be.  The topic deserves its own post, but, in short, the NCCAOM is a credentialing agency. They design, administer, and maintain the process by which most of us are able to be licensed.  There are loads of consequences of their power within our profession, especially because we have not had, for some time, a truly effective or well-functioning national professional association.

There were many complaints that the NCCAOM hadn’t done more to “stop dry needling.” That, combined with yesterday’s urgent petition regarding legislation on the Governor’s desk in Delaware, made we think I’ve got to try, one more time, to explain where we are with the issue and why what we’ve been doing won’t work. My post to my alumni group is out of context, but I hope still worth sharing (somewhat edited for clarity) —

Since Dry Needling is the issue that keeps coming up as a major focus for the profession, I wanted to give a little more info about the “court rulings” in our favor.

The one that received the most notice and attention was the case in Oregon regarding Chiropractors and Dry Needling.  The outcome of the case was widely misrepresented within the acupuncture community. Various stories indicated that the courts said that dry needling was acupuncture or that it had been determined that the training programs were insufficient.  This was not the case.  You can read a fuller explanation of the outcome of the case here – https://theacupunctureobserver.com/a-practical-next-step/. The gist of the ruling is that dry needling does not meet the implied definition of physiotherapy within the Oregon code.

Other states have also had rulings (usually informal) from the Attorneys General stating that dry needling is not within PT scope.  These rulings have typically been much celebrated within the acupuncture community, but we haven’t been hearing what happens next.  For instance, some time ago Utah was celebrating such a ruling.  Since that time, legislation added dry needling to the scope of physical therapists.  Similar legislation passed in Arizona.  When the AG recently ruled that dry needling was not within PT scope in Tennessee, the ruling included phrasing that basically said, PT’s will need to address this legislatively, as was done in Utah.  (You can get the link to the ruling here — https://theacupunctureobserver.com/late-july-acupuncture-news/).  Illinois is another state where the AG’s latest opinion agreed with the argument that dry needling was not within PT scope, but where the PT groups are already preparing legislation for the next session.

There will probably be states where the acupuncture community is large enough and well-connected enough (and Maryland might well be one) where similar legislation would not be successful, but if you look at the numbers in most states, the PT’s (who also often have business connections with the medical establishment) are likely to prevail.

Today I received a notice of a petition regarding DE HB 359, adding dry needling to the scope of PT’s in Delaware.  HB 359 passed by overwhelming majorities in the House and Senate and needs only the Governor’s signature.  Among the “gems” in the petition – “Accordingly, HB 359 will potentially place the general public in significant danger of injury and harm due to unsafe and unqualified needle practices.”  There are about 800 PT’s in DE, and even more PT Assistants.  There are 45 LAcs.  The odds of the Governor exercising his veto are slim, the odds of pissing off 800 PT’s?  Pretty good, considering we’ve just stated they are putting the public in significant danger.  Interestingly, one of the authors of this petition is the same person who pushed for the requirement of the NCCAOM OM credential in DE, putting practice off limits to about 70% of US acupuncturists.  Isn’t it ironic that the profession’s self-imposed restrictions on licensure in Delaware have left the LAcs scrambling to block action by an overwhelmingly larger group?

Had LAcs been more willing to work with the PT’s from the start, I suspect that in many jurisdictions we’d have come out ahead.  We’d have built relationships and understanding and had some influence, perhaps, on how this modality is practiced.  By sending PT’s to the legislative fix (that’s what “we” said right from the beginning – if they want to do this they should do it legislatively) we’ve taken ourselves out of the process.  As they succeed with changing the law we’ve lost any influence on the procedure.

Of course, trying to work together might not have changed anything.  Professions (including our own) are universally unhappy about outsiders coming in to tell them what they should do and how they should do it.

I will add three things in response to the previous post.  1) While I appreciate the frustration felt by LAcs when dry needling and acupuncture are spoken about as being equivalent, hasn’t it been our insistence that dry needling IS acupuncture that led to this? Wouldn’t we be better served by clarifying the distinction between the two? (Of course, that would undermine our argument that we have a right to regulate the procedure.)  2) There are many cases of patients not wanting to report harm suffered at the hands of providers.  This happens among acupuncture patients too. Even LAcs can cause a pneumothorax.  3) The cease and desist orders can’t help but remind me of the stories from decades ago of acupuncturists being threatened with arrest for practicing medicine without a license.

It hasn’t taken long for us to go from being the scrappy upstarts just wanting to help people with a simple technique, and frustrated by the establishment that was trying to shut us down, to acting like the establishment.  We’ve got our ever-increasing credentials, and maybe specialties soon, and are increasingly able to participate in the bureaucratic system of figuring out which set of codes gets us a reimbursement we can live with. Now, in Maryland, LAcs can interfere with a citizen’s ability to choose what treatments they get from which providers, and can throw their weight around in the provider community.

PT’s will outnumber us for a long time to come.  It’s a shame we’ve pissed in that particular well.

 

Five Important Dry Needling Developments

Yes, more on dry needling.  More about education will have to wait.

Five things to know —

  1. The Oregon Ruling did not (despite the Acupuncture Today headline) determine that “Dry Needling is Acupuncture.”  For a full exploration of the case, read this post. In summary, the ruling of the court was that Dry Needling is not physiotherapy.
  2. On April 1st Utah Governor Gary Herbert signed HB 367, legislatively adding Dry Needling to the scope of Physical Therapists.
  3. On April 24th Arizona Governor Jan Brewer signed SB 1154, legislatively adding Dry Needling to the scope of Physical Therapists.*
  4. On March 25th Massachusetts HB 3972 advanced. This redraft of acupuncture bills HB 2051 and SB 1107 was necessary because the bill could not advance with the language that “dry needling is acupuncture.”
  5. At the end of April the Illinois Department of Professional Regulation issued an informal ruling that dry needling was not within the scope of practice for Physical Therapists “as the acts are currently written.”  That last phrase is important. From what I can tell there are about 550 LAcs in IL and over 9,000 PT’s.  The PT’s aren’t ready to call it quits. Time will tell if the victory for the LAcs is a lasting one. The PT’s could well look to Arizona and Utah and work for a legislative change.

(A colleague practicing in Delaware recently told me of the urgent phone calls and emails she’s been receiving — she must get involved in the fight against PT Dry Needling! Delaware is a state in which a few LAcs on the Advisory Board refuse to grant licenses to qualified acupuncturists. There are so few LAcs (less than 40) that they can’t maintain an association and citizens are far more likely to get acupuncture from a DC or an MD than an LAc. Now the profession wants to take on the PT’s? If there’s an urgent need for action from the LAcs of DE, perhaps it should be action to bring LAcs to the state?)

For those who insist we must do something about this serious risk to our profession, here are some suggestions. They would do far more to benefit our profession than this ongoing battle with the PT’s.

* One of the acupuncture profession’s strategies from the start of the Dry Needling issue was to argue, as the AAAOM wrote in their 2013 position paper,– “the addition of TPDN to physical therapy practice is being determined by physical therapy regulatory boards, deleteriously circumventing transparency and public health safety protections provided by standard legislative process.”  This was a mistake. Given the relative political strength of the PT profession and their MD supporters legislative victories are likely. Had we been willing to work with our health-care colleagues in the regulatory arena we might well have had input and influence in the use of this procedure.

Acupuncture Education

Between conversations on Facebook, dialogues on list serves, and college tours with my child, I’ve been thinking about acupuncture education a lot recently. There are several topics I plan to address in the next few weeks.  First off —

To those considering becoming an acupuncturist:

  • Talk to practitioners in your area. Do they recommend the school they attended? (Ask if they are employed by the school in any capacity to help evaluate their response.) Are most of their classmates are still in practice? How long did it take them to establish a successful practice? (How do they define success?) Are they easily able to make their student loan payments? Are they on an income-based repayment plan?
  • What percentage of the school’s graduates are still in practice 3/5/10 years out. The admissions office should be able to tell you this. They won’t be able to. Don’t be fooled – knowing the percentage of students passing the credentialing exams is not sufficient data to make a major investment. And make sure to ask what they mean by “still in practice.”  Here’s one school’s information about graduate success.
  • Will the education you receive at the school enable you to practice in the states you might want to practice in. Verify the information the schools provide, as many students have been misled. State requirements vary and are changing. Some only approve graduates of particular schools, some require additional education in certain subjects, some are very specific about whether the school has full ACAOM accreditation (ACAOM approved, or ACAOM candidate status won’t do it).
  • While schools may say that LAcs are employed in hospitals and other health care settings, know that this is a tiny percentage of practitioners. The vast majority of practitioners are establishing their own private practices upon graduation. What are the schools business classes like? Do they bring in marketing experts, accountants, lawyers, to give you guidance?
  • In a recent NCCAOM survey 62% of respondents reported a personal income, before taxes, of less than 65K.  Most “employment” situations for LAcs do not include sick time, paid vacation, family leave, health insurance, disability insurance, retirement savings plans, or payment for time spent on administrative tasks. If you are thinking oh, 30 clients/week at $80.00 = $124,000 — I’ll be rich, you should think again.Your ongoing expenses are likely to include fees for licensure, your NCCAOM credential, the CEU expenses to maintain that credential, malpractice insurance, liability insurance for your office, rent and utilities, marketing, supplies, taxes (of course) which are higher for the self-employed. If you intend to work within the insurance system know that while you may build a practice more quickly, the amount you receive as reimbursement can be changed at the whim of the insurance company. Expect that some amount of your time and money will be spent on additional services to help you track and pursue reimbursements.

Don’t get me wrong.  Many practitioners love what they do and wouldn’t trade it for anything.  This includes people who admit that they are struggling financially. I’m not saying don’t go to acupuncture school. I am saying do the research you would do before any other 80K (or more) purchase.

AAAOM News Flash

AAAOM Dysfunction — finally getting the attention it deserves.  Thank you, Acupuncture Today, for finally taking a closer look at what is going on behind the scenes.

Assistance for the Working Acupuncturist

I went down the Facebook rabbit-hole, and while I was there I learned a few things.

For instance, “just a quick look” and “I’ll just scan my notifications” can quickly lead to a month without a blog post. I will not let that happen again.

Also, based on posts about HIPAA, insurance billing, choosing office space, maintaining records, etc., we have  a lot of questions and we are looking for answers. It’s great that we’ve got communities of colleagues to ask. It is also inefficient, and sometimes downright dangerous that our colleagues are often the only source of answers.

Looking at HIPAA and ADA for example, we see that some professions (but not acupuncturists) have access to lots of resources from their national associations.

  • a search of the AAAOM site gets one, not very useful hit, regarding HIPAA-related responsibilities.
  • Here’s information from the APTA (American Physical Therapy Association) site on HIPAA.
  • Here are the search results for HIPAA over at the American Chiropractic Association.
  • I can find no information on the AAAOM site about acupuncture offices and ADA compliance.
  • APTA provides these useful links about ADA compliance.
  • The American Psychological Association has great information about ADA compliance.

While acupuncture organizations are working on national legislation, increasing insurance coverage for acupuncture, adding an entry level degree, and fighting with other professions to limit the use of the acupuncture needle, we search for authoritative assistance on current practice issues in vain. (Luckily, the links above are pertinent to our practices.)

To make matters worse, sometimes it seems that we prefer ignorance. In my time on Facebook I was reprimanded for self-promotion when I shared useful links to this blog, and I was threatened with banishment from Acupuncturists on Facebook because I “acted like [I] know it all.” (I don’t know it all. I do know a few things.)

When many of us don’t understand or comply with our obligations under the ADA and HIPAA, are we ready to be a part of the Medicare system or have acupuncture be an EHB? Isn’t accurate information about ADA compliance an important part of our stated goal of having acupuncture accessible to all? It’s past time for our schools and organizations to make sure we have the skills, knowledge, resources and information to be successful practitioners now. The FPD, Medicare inclusion, higher standards, and expanding our scope/suing our competitors should wait.

The Acupuncture Profession, News and Analysis

Three dedicated AAAOM Board members and AAAOM (super-qualified, knowledgeable, and committed) Executive Director, Denise Graham (my last hope that things could get better) resigned recently.

One board member spoke of an uncomfortable and increasingly controlled board environment, a declining membership (now less than 2% of the profession), and poor relationships with national and state leaders. Another stated that the AAAOM doesn’t have the support, revenue, or credibility to make progress towards legislative goals.

This isn’t the first time AAAOM has been on the ropes. If it hadn’t been for money from the AAC and support from other organizations, I doubt they would have survived this long. Somehow, though, they still manage to control the conversation.

In other news, NCASI, the National Center for Acupuncture Safety and Integrity, has appeared on the scene. NCASI’s list of “10 Facts” should be titled “10 Things We Insist are True and/or Important.”  Dry Needling by PT’s is legal in many states. Review my past posts on dry needling and scope for more background. We take real risks when we files lawsuits like these.

For twenty years, the acupuncture organizations have insisted that our success depends upon —

  • Increasing credentials/educational requirements/scope. It doesn’t matter if the old education, credentials, and scope worked fine. It doesn’t matter if it increases practitioner expense, decreases practitioner flexibility, or prevents some LAcs from utilizing techniques available to any other citizen.
  • Getting someone else to pay for acupuncture. Fight for third-party payment systems even if other professions report they make good medicine more difficult and practice less enjoyable. Ignore the hypocrisy of participating in a system that requires discounting services while also criticizing LAcs who offer low-cost or discounted treatments directly to patients. Insist that practitioners who don’t want to participate won’t be impacted, and turn a blind eye to the fraud that many practitioners engage in to make the $’s work.
  • Demanding a monopoly.  There’s no need to earn your market share by providing the best product — instead establish it through litigation and turf battles. Don’t worry if this requires you to disparage your fellow health providers or contradict your message that the public should be able to choose their providers.

After twenty years many LAcs struggle to stay in business, and most voluntary acupuncture organizations struggle to survive. Got questions about ADA compliance, insurance billing, privacy issues, advertising questions, disciplinary actions? You won’t get answers from the AAAOM and you probably won’t get them from your state organization.

It’s time to change our strategy. We have enough training, clients who seek our services, and other providers who respect the medicine so much they want use it themselves. Yes, we always need be aware of and informed about the regulatory/legislative landscape, but we also need business skills, PR, positive marketing, and an easing of the regulatory burden.  We need a good hard look at the cost of education. We need legal advice and business tools and positive interactions with potential referral sources and colleagues. We don’t need more legal battles, more regulation, more legislation, more degrees that further divide us.

When our organizations provide these things, we’ll have successful organizations, and successful practitioners. (If you don’t believe me, ask POCA.)

 

Dry Needling, Herbs, and Scope — How to Regulate a Profession

A regulatory Board is contacted.  Your licensees are doing X, that isn’t (or, is that?) in your scope.

Ask a PT Board about Dry Needling and the answer usually goes something like this — We trust our licensees. Many learn this technique and it helps their clients. We find room in our regulation to include this in our scope.  We have a few concerns and suggest that those who want to utilize this technique have some additional training and take additional precautions. Our existing system for addressing unsafe practice is sufficient to address risk to the public.

Ask an Acupuncture Board or organization about herbs and the answer usually goes like this. We are being threatened again!  We’d better legislate, and fast! Help! Thanks NCCAOM and schools. We are so grateful for your efforts to ensure that any acupuncturist who wants to utilize this dangerous aspect of our medicine add your $20,000 education and your formal $800.00 seal of approval to their already extensive education and credentials. In fact, in the name of raising standards we should require that from all LAcs. It might prevent some of our most qualified practitioners from practice, but, hey, it is a step toward getting the respect we deserve.

Is something wrong with this picture?

It’s a radical idea, but how about we respect ourselves. Let’s recognize the safety of our medicine and the depth of our education.  Let’s trust our colleagues’ professional judgement and open doors rather than close them and let’s stop deferring to those who profit from our love of this medicine.

For additional reading, check out an example.  In this case, I agree with Dr. Morris when he wrote,

To avoid conflicts of interest, no individual who stands to profit from seminars should determine competencies and educational standards, nor should they testify in legislature on behalf of the common good.

(Of course, he was talking about the PT’s when he wrote it, so maybe in this case he doesn’t agree with himself.)

You have until Monday, 9/30, to comment on the NCCAOM’s “proposals.” Does the current CEU arrangement put the public at risk? Are the states incapable of effective regulation?

One more thing — during the great FPD debate, many expressed concern that once the degree was available the NCCAOM could, by fiat, require it for entry level practice. We were assured that would be impossible. Informed by history, it seems very possible indeed.

A Very Important Question

Dear NCCAOM,

Will feedback received influence your proposed(?) policy changes?  Ms. Basore’s comments to my previous post indicate the changes are a done deal. Please let the readers of The Acupuncture Observer know so that we can effectively use our qi.

Thank You.

Dear Readers,

I’ll send my many questions and comments about the policy changes to the NCCAOM (and post them here) if our input matters.  In the meantime, please  —

  • Contact NCCAOM via Facebook to weigh in on the proposed(?) changes. (Are they listening?)
  • Contact AAAOM via Facebook to share your thoughts on the NCCAOM’s proposed(?) changes.
  • Respond to the AAAOM’s latest Call for Comments (deadline September 19th), and let them know if you think they should be focusing on the proposed(?) changes.
  • Contact your state professional association to point out that the proposed(?) changes interfere with the state regulation of acupuncture and ask them to get involved.
  • Ask your state association to raise this topic with the Council of State Associations. (There doesn’t seem to be any way for the average professional to contact that group directly.)

That’s a good start while we wait to hear back from the NCCAOM. Oh, and spread the word!

P.S.:  Here’s a story about background checks.  Keep in mind, in the NCCAOM’s proposal, the poor applicant wouldn’t even be allowed to sit the exams.

Proposed(?) NCCAOM Changes

September 30th is the deadline to submit feedback on the NCCAOM’s proposed(?) policy changes.  These changes will impact the profession and may impact you. Don’t be taken by surprise and don’t let the profession change without your input. Weigh in! (Why the question mark after the word proposed? Because according to the latest NCCAOM spotlight, the criminal background check is already in effect.)

There are Four Proposed(?) Policy Changes.  As you prepare your feedback you will benefit from reading the NCCAOM’s Summer Newsletter for information on the NCCAOM’s role in the profession (which I will write more about soon) and for details of the proposed(?) criminal background check policy.

Here is my input to the NCCAOM (my email bounced back, so I’m sending via snail mail) —

As an NCCAOM Diplomate in Acupuncture, a member of the Virginia Advisory Board on Acupuncture, and a past board member of the Acupuncture Society of Virginia and the AAAOM, I share the following input on your proposed policy changes (which reflect my personal views and not the opinion of any board or organization)….

1)      The public and the profession would benefit from requiring a reasonable degree of English proficiency of NCCAOM Diplomates.  This goal is best met by requiring an intermediate score on the TOEFL or by other documentation of proficiency.  The NCCAOM should continue to offer the credentialing exams in other languages.  Many experts in this medicine were educated and trained in foreign languages.  Many great scholarly works are not available in English and much is lost in translation. Continuing foreign language testing, while requiring documentation of English proficiency would ensure that NCCAOM Diplomates can communicate effectively with regulatory boards and the public, while also allowing the study of the medicine in the language which best serves the practitioner.

(Since writing this I realized that all of the language requirements fall outside the NCCAOM’s mission of determining competency. Language requirements should be left to the states.)

2)      Based on the Summer NCCAOM News, input regarding criminal background checks for applicants is being requested after the policy change has been implemented. That is unfortunate.  Reporting that the “appropriate” staff will review each case is not helpful.  Who is the staff and what is their training?  Is this policy change in response to specific failings of the current credentialing and licensing process, or is it a preemptive jump on the bandwagon? In the absence of evidence that harm has occurred that would have been avoided had the policy been in place it is unnecessarily invasive and potentially discriminatory and should not be implemented.

3)      The PDA Provider Categories policy changes, especially the changes that seem to have been already established for 2015, will be detrimental to the profession and the public. While many professions trust licensees to obtain CEU’s useful to the needs of the practitioner, the NCCAOM’s increasingly restrictive policies seem designed to benefit only the coffers of the NCCAOM.  I have not found NCCAOM PDA providers to offer a higher caliber of class or to provide the range of classes that would be most useful to my practice.  I resent the degree of control the NCCAOM has over my continuing education through these changes and the hidden “tax” you will receive from every PDA point I earn.

These proposed changes contribute to my increasingly strong opinion that states should move away from requiring ongoing Diplomate status. (Since writing this I realized that because these policy changes impact who can sit the exams, getting away from the NCCAOM ongoing credentialing won’t address the issue.  Until the NCCAOM ceases the standard inflation that has begun to feel like a shakedown, I’ll support states developing an alternate path to licensure that doesn’t depend upon the NCCAOM.)  While I see the benefit in establishing a minimal level of education through the NCCAOM exams, your proposed policy changes work against the diversity that is an important part of Asian Medicine. Tightening the stranglehold on acupuncturists benefits neither the profession nor the public as increasing numbers seek our services.

Sincerely,

Elaine Wolf Komarow, LAc, NCCAOM 005020